I. Consultation and Initial Evaluation |
|
|
|
Cost |
|
A. Consultation |
1) New Patient (99205) |
$330.00 |
|
|
2) Established Patient (99243) |
$200.00 |
|
B. Laboratory Test |
1) Rubella (86280) |
$38.00 |
|
|
2) HIV (86701) |
$89.00 |
|
|
3) VDRL (RPR) (86592) |
$43.00 |
|
|
4) Hepatitis B (86287) |
$89.00 |
|
|
5) Hepatitis C (86302) |
$89.00 |
|
|
6) FSH (83001) |
$73.00 |
|
|
7) LH (83002) |
$73.00 |
|
|
8) Estradiol (E2) (82670) |
$144.00 |
|
|
9) Phlebotomy (36415) |
$21.00 |
|
10) Semen Analysis (89321) |
$115.00 |
|
11) Cystic Fibrosis (83890) |
$405.00 |
|
C. Sonohysterogram |
(76831/58340/58345/J2912) |
$789.00 |
|
|
TOTAL (varies)
|
$2,498.00
|
II. Medications (approx.)
|
|
|
|
|
|
Unit Cost |
Used |
Cost |
|
A. Lupron |
$150.00 |
2 |
$300.00 |
|
B. Stimulation Meds |
$47.00 |
50 |
$2395.00 |
|
C. Ovidrel |
$69.00 |
1 |
$69.00 |
|
D. Progesterone in Oil |
$45.00 |
3 |
$135.00 |
|
E. Syringes |
$30.00 |
- |
$30.00 |
|
|
TOTAL (varies)
|
$2,929.00
|
III. Cycle Monitoring
|
|
|
Baseline |
|
Cost |
|
1) BHCG (847O2) |
$58.00 |
|
2) Pre Lupron Progesterone (84144) |
$120.00 |
|
3) Ultrasound (76830) |
$330.00 |
|
4) Estradiol (82670) |
$144.00 |
|
5) Phlebotomy (36415) |
$21.00 |
Follow-up*
|
|
|
1) Ultrasound (76857) |
$144.00 x 4 |
|
2) Estradiol (82670) |
$144.00 x 4 |
|
3) Phlebotomy (36415) |
$21.00 x 4 |
|
TOTAL (varies)
|
$1,909.00 |
* There may be several follow-up monitoring visits, with an average being four (4).
|
IV. Egg Retrieval |
Cost |
|
1) Egg Retrieval (professional) (58970) |
$2,300.00 |
|
2) Ultrasound Guidance (76948) |
$630.00 |
|
3) Ultrasound Needle (99070) |
$158.00 |
|
4) IV Anesthetic (01995) |
$230.00 |
|
5) Oocyte Identification (89254) |
$578.00 |
|
6) Egg Assessment and Culture (89250) |
$2,300.00 |
|
7) Semen Analysis (89320) |
$100.00 |
|
8) Sperm Preparation (89261) |
$289.00 |
|
9) IV Fluids (90780) |
$173.00 |
|
10) Anesthetic Medication (99070) |
$131.00 |
|
11) Pulse Oximeter (94761) |
$115.00 |
|
12) EKG (93041) |
$115.00 |
|
TOTAL (varies)
|
$7,119.00 |
V. Embryo Transfer
|
|
|
1) Transfer (professional) (58974) |
$892.00 |
|
2) Transfer Catheter (99070) |
$158.00 |
|
3) Preparation of Embryo for transfer (89255, 89252) |
$525.00 |
|
4) Ultrasound guidance of transfer (76805)
TOTAL (varies) |
$131.00
$1,706.00 |
VI. Post Embryo Transfer Monitoring
|
Cost |
|
1) BHCG (84702) |
$58.00 |
|
2) Phlebotomy (36415) |
$21.00 |
|
TOTAL (varies)
|
$79.00 |
If Pregnant
|
|
|
1) BHCG (84702) |
$58.00 |
|
2) Progesterone (84144) |
$120.00 |
|
3) Phlebotomy (36415) |
$21.00 |
|
4) Pregnancy Ultrasound (76805) |
$330.00 |
|
TOTAL (varies)
|
$529.00 |
VII. Possible Additional Fees
|
Cost |
|
1) Assisted Hatching (89253) |
$662.00 |
|
2) Intracytoplasmic Sperm Injection (ICSI) (89252) |
$1,575.00 |
|
3) Embryo Freezing (89258) |
$578.00 |
|
4) Embryo Thawing (89256) |
$630.00 |
|
5) Embryo Storage
(Billed in advance-minimum (3) months) |
$25.00/month |
|
6) Sperm Identification (89264) |
$525.00 |
|
7) Extended Blastocyst Culture (89272) |
$525.00 |
VIII. Anesthesia*
|
Cost |
|
1) Professional |
$400.00 |
* Check, cash or money order only. No insurance billing.
|
